Insurance Information and Courses from MediaLab, Inc.

HIPAA applies to: Health Plans (such as health insurance companies) Healthcare Clearinghouses (such as billing companies), and Healthcare Providers (including doctors, hospitals, laboratories, and pharmacies). HIPAA refers to these 3 groups as covered entities.

All employees have a responsibility to maintain the confidentiality of medical information. Medical information should never be discussed outside of the laboratory. It should only be discussed with the ordering doctor or an authorized representative of the doctor. Employees should verify the identity of the individual requesting such information Employees who communicate with patients, physicians or their office staff, insurance company representatives or government employees about any laboratory activity should only give information they know to be true and accurate. Employees should never give false information and should never guess the answer to any question. In case of doubt, refer the person to a supervisor.

A billing clerk is entering billing demographics on requisitions as a part of the normal days work. The department is under pressure to reduce accounts receivable, which means that the more clean claims that are filed, the better. This particular requisition is for a Medicare patient and has an LMRP test but does not have a diagnosis on it. She remembers that just a few requisitions before this one she had a requisition from the same doctor that had this same test on it that did have a diagnosis that allowed the test to be billed. She thumbs back in the pile and finds the previous requisition, notes the code that was used and adds it to the current requisition. This will help her meet the department goal of getting claims paid and reducing accounts receivable. It is all right for her to do this because:Correct Answer: She should not do this because it is against the law to change diagnosis information on a requisition.Discussion: A laboratory employee should never change, add or use previously received diagnosis information for the purpose of making a test billable for the Medicare program or for any other insurance or payer. This is a form of fraud and for each claim submitted as a result of this activity the laboratory is liable for a false claim and would have to pay the government back three up to times the reimbursement for the test and up to $10,000 for each claim submitted. Further, if the employee is caught doing this, even if the employee is ignorant of the law and any laboratory policy prohibiting it, she must be disciplined and so should the supervisor. Any employee who notices another employee doing this should correct the employee and report the incident to the department supervisor immediately.